The British Journal of Psychiatry (2020)
Page 1 of 2. doi: 10.1192/bjp.2020.165
Editorial
Is mindfulness for psychosis harmful?
Deconstructing a myth
Kerem Böge*, Neil Thomas* and Pamela Jacobsen*
Summary
Mindfulness-based therapies are increasingly available for a
range of mental disorders, such as depression and anxiety.
However, there remain concerns that mindfulness has the
potential to exacerbate psychosis, despite a growing body of
literature demonstrating effectiveness. These concerns may
relate to long-standing perceptions about the suitability of
offering psychological therapies to people with psychosis.
Kerem Böge (pictured) is a clinical psychologist, researcher and lecturer in the
Department of Psychiatry and Psychotherapy at Charité – Universitätsmedizin Berlin,
Germany, focusing on the development of novel psychotherapeutic approaches, their
process and outcome for schizophrenia spectrum disorders. Neil Thomas is the Deputy
Director of the Centre for Mental Health at Swinburne University of Technology, Australia,
and a researcher on psychological interventions for psychosis. Pamela Jacobsen is a
clinical psychologist and researcher in the Department of Psychology, University of Bath,
UK, specialising in psychological therapies for psychosis, including cognitive–behavioural
therapy and mindfulness-based approaches.
People with psychosis always seem to get everything last. Cognitive
therapy for depression and anxiety disorders were well-established
in the evidence base by the 1980s, but cognitive–behavioural
therapy (CBT) for psychosis did not make it into clinical guidelines
in the UK until 20 years later, and another 12 years after that in
Germany. Furthermore, relative to common mental disorders such
as anxiety and depression, implementation of these guidelines for
psychosis has been much more limited in routine clinical practice.
Similarly, although mindfulness-based cognitive therapy (MBCT) is
now recommended in the National Institute for Health and Care
Excellence (NICE) guidelines for the prevention of relapse in depres-
sion (www.nice.org.uk/guidance), concerns from clinicians that
mindfulness is harmful for people with psychosis or can trigger
psychotic episodes in vulnerable individuals are common.1
What do we know about harm in mindfulness-based
interventions?
Psychological therapy is one of the key pillars in the treatment of a
wide range of mental illnesses, but the potential adverse effects of
psychotherapies still remain less systematically studied than those
of medications and medical devices and the field lacks agreed ter-
minology. In this context, decisions about what to provide to
whom may be more influenced by presumptions about what may
happen than informed by the available data. A variety of outcomes
have been identified as potential adverse effects of psychotherapy,
such as a lack of clinical improvement, symptom deterioration,
development of new symptoms, fear of seeking future treatment
and maladaptive dependence on therapists.2
Duggan et al have defined harm as any ‘sustained deterioration
that is caused directly by the psychological intervention’.2 Using this
* Joint first authors.
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Keywords
Mindfulness; psychosis; schizophrenia; harm; psychological
therapy.
Copyright and usage
© The Authors, 2020. Published by Cambridge University Press
on behalf of the Royal College of Psychiatrists.
definition, it is therefore important to distinguish between short-
term discomfort, which can be considered part of therapeutic
growth, and serious or long-term harms (serious adverse effects).
What we encounter in mindfulness practice is often challenging,
as we explore deeper through the many layers of our human experi-
ence, much of which we may be used to keeping shut away.
Mindfulness therefore represents a journey of reacquaintance with
difficult thoughts and emotions that we may have become discon-
nected from. Short-lived periods of discomfort should therefore
be the rule, rather than the exception, for people engaging in mind-
fulness-based interventions. However, a recent review of clinical
trials of such interventions concluded that adverse effects were
overall rare (reported by 0–10% of all participants) and not found
to be directly attributable to the mindfulness intervention.3 The
review’s authors therefore concluded that mindfulness can be
uncomfortable without being harmful.
Why specific concerns about mindfulness for
psychosis?
Historical concerns about use of mindfulness in psychosis can
perhaps be linked to the over-reliance on early uncontrolled case
study evidence which suggested that people developed psychotic
episodes after taking part in meditation retreats.1 For example,
Walsh & Roche4 report three cases of apparent psychotic relapse
in people diagnosed with schizophrenia who had taken part in
intensive meditation retreats. The retreats were described as involv-
ing ‘many hours each day of sitting and walking meditation and
total silence, without communication of any kind (even eye
contact)’ and up to ‘18 hours of meditation a day’ over the course
of a 2-week retreat. This bears little resemblance to the intensity
and mode of delivery that would be typical of mindfulness-based
interventions in mental healthcare settings. Furthermore, we
know that sensory deprivation, social isolation, fasting and sleep
deprivation are themselves risk factors for relapse in psychosis,
and so these are likely to have been the riskiest aspects of the
retreat rather than the meditation itself.
What does the current literature on mindfulness for
psychosis show?
There have been at least a dozen randomised trials of mindfulness-
based interventions for psychosis, with a combined sample size of
over 1300, as well as several other trials of interventions in which
1
Böge et al
mindfulness exercises are used (e.g. acceptance and commitment
therapy; compassion-focused therapy). A recent meta-analyses of
trial results indicated that interventions including mindfulness as
a primary component show beneficial effects in various symptom
dimensions, compared with treatment-as-usual and waiting-list
conditions.5 This indicates that, on average, mindfulness is more
likely to be beneficial than harmful in psychosis. Furthermore,
examination of reports of study withdrawals showed no evidence
of withdrawals arising from psychotic exacerbation during
therapy, and trials have consistently shown a similar rate of withdra-
wals between mindfulness and control arms. Studies have also
shown rates of treatment drop-out from mindfulness-based inter-
ventions to be no greater than for compared treatments. A series
of studies have additionally tracked hospital admissions following
mindfulness integrated with psychoeducation and found that mind-
fulness was associated with similar or lower hospital admission rates
during and following therapy compared with control groups.
What can we take from this?
The belief that it is dangerous to invite people with psychosis to
intentionally ‘turn towards’ their experiences remains present
among clinicians and is perhaps connected to fears that it is danger-
ous to talk to people about their delusional beliefs or unusual experi-
ences because this exacerbates their symptoms. There is a rich
history of the ‘othering’ of psychotic experiences in psychiatry as
something enigmatic and apart from normal human experience.
However, patient advocacy groups have fought hard to overturn
this fallacy, to be viewed not as less-than-human enigmas but as
fully human beings. Turning towards our inner experiences may
often be challenging, but there is no rationale for psychotic symp-
toms such as voices or delusions to be placed in a separate ‘category’
apart from normal human experience. In fact, there is now increas-
ing evidence for the use of mindfulness in the treatment psychosis
that reports safety, acceptability and clinical efficacy.
People with psychosis are among the most marginalised and
discriminated against in society, and unfortunately experience sig-
nificant inequalities both in their physical health outcomes, for
example reduced life expectancy, and in the insufficient access
they often have to evidence-based psychological therapies. A pater-
nalistic attitude among clinicians about ‘protecting’ people from
potentially harmful effects of psychological treatments can no
longer be considered benevolent if these attitudes are unfounded
and based on assumptions about the ‘otherness’ of psychotic experi-
ences. We argue that early uncontrolled case studies reporting
harmful effects of meditation for people with psychosis may have
coalesced with ongoing clinician concerns about the viability of psy-
chotherapeutic approaches in the treatment of psychosis. This may
have led to an underdevelopment of the evidence base over the past
20 years, particularly with respect to a paucity of large, well-con-
ducted randomised controlled trials of mindfulness for psychosis.
There is, however, clear interest in the question of the effectiveness
of mindfulness for psychosis, given that numerous meta-analyses
2
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and systematic reviews have been published in the field (at least
10 review articles since 2013). Existing data show that mindfulness
for psychosis can be implemented safely, if delivered by experienced
clinicians with appropriate mindfulness training and supervision, in
both in-patient and community routine care settings. Adaptations
to delivering mindfulness for psychosis include delivery in
smaller groups, shorter duration of meditation, avoiding prolonged
periods of silence, and using basic anchoring techniques and easily
accessible and simple language.
For future research, we suggest a priority should be better
systematic assessment of side-effects and adverse events of mindful-
ness for psychosis in large trials, in line with the recommendations
of Baer et al,3 who noted that the potential harms of mindfulness are
an under-researched topic. This will facilitate an improved under-
standing of the processes and mechanisms of psychotherapeutic
change within mindfulness-based interventions for psychosis, to
allow the field to develop and evolve according to evidence-based
practice. In the interim, we recommend that people with psychosis
are not denied access to mindfulness-based treatments purely on the
basis of their diagnosis and/or symptom profile.
Kerem Böge , Department of Psychiatry and Psychotherapy, Campus Benjamin
Franklin, Charité – Universitätsmedizin Berlin; and Freie Universität Berlin; and Humboldt-
Universität zu Berlin; and Berlin Institute of Health, Germany; Neil Thomas , Centre for
Mental Health, Swinburne University of Technology, Australia; Pamela Jacobsen ,
Department of Psychology, University of Bath, UK
Correspondence: Dr Kerem Böge. Email: kerem.boege@charite.de
First received 30 Apr 2020, final revision 13 Jul 2020, accepted 30 Aug 2020
Author contributions
All authors contributed equally to the drafting, revision and final approval of the manuscript.
Declaration of interest
None.
ICMJE forms are in the supplementary material, available online at https://doi.org/10.1192/
bjp.2020.165.
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